Dean, Kathy E ii...H\LT)
N EW YORK STATE DEPARTMENT OF H EALTH
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Kathy E. Dean Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/30/2022 67 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Saratoga Springs Street Address Saratoga Hospital
p Manner of Death X❑Natural Cause Accident ❑Homicide []Suicide EIUndetermined ❑Pending
W
U Circumstances Investigation
W Medical Certifier Name Title
CI Sergio Lema-Gutierrez MD
Address
211 Church St,Saratoga Springs, New York 12866
Death Certificate Filed City Of Saratoga Springs District Number Register Number
City,Town or Village 4501 781
RBurial Date Cemetery,Crematory or Facility Name
01/03/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town, New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
Q. Date Point of
U)OTransportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
[]Reinterment
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
5 Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/03/2023 Registrar of Vital Statistics Dillon Moran(Electronically Signed)
(signature)
District Number 4501 Place City Of Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
11.1
Date of Disposition ))5 �
�2; Place of Disposition 'address)
W
(lotU)
CC nu ber) (grave number)
(section) y
O Name of Sexton or Person in Charge Premises • // 1L �' i`,
Q (p(e a print)
Z �IZF'Y19"1
Ill �—• Title
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of _ _ delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#